Coroner's Finding: CATALANO Fernanda

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 5th day of February 2019 and the 15th day of April 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Fernanda Catalano.

The said Court finds that Fernanda Catalano aged 85 years, late of the Italian Village, 6 Mumford Avenue, St Agnes, South Australia died at the Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia on the 24th day of April 2016 as a result of ischaemic heart disease with renal failure. The said Court finds that the circumstances of her death were as follows:

1. Introduction and cause of death 1.1. Fernanda Catalano was 85 years of age when she died at the Lyell McEwin Hospital on 24 April 2016. A post-mortem was conducted by Dr Neil Langlois from Forensic Science South Australia in relation to Mrs Catalano’s death. In his report1 Dr Langlois gave the cause of death as ischaemic heart disease with renal failure, and I so find.

1.2. The report stated that biochemical analysis of the vitreous fluid of the eyes and the cerebrospinal fluid confirmed renal failure. There was also scarring in the heart, in keeping with the previous ischaemic damage.

1.3. Dr Langlois stated that Mrs Catalano's troponin on admission to hospital was high, however this would have been raised due to the presence of her renal impairment. The findings suggest an acute cardiac ischaemic event due to her ischaemic heart disease, 1 Exhibit C2

leading to renal failure, with a likely final mechanism of death being a cardiac arrhythmia in response to biochemical derangement.

2. Reason for Inquest 2.1. At the time of Mrs Catalano’s death she was subject to a Guardianship Board order under section 32 of the Guardianship and Administration Act 19932.

2.2. On 12 June 2013 an application was made to the South Australian Civil and Administrative Tribunal (SACAT) by Hampstead Rehabilitation Centre for an administration order and guardianship order. On 28 June 2013 the application was granted and Mrs Catalano's sons were appointed as guardians. The order was due for review in June 2016.

2.3. On 21 March 2016 a further application was made, followed by an urgent request on 23 March 2016. As a result the previous order was amended to include provisions which allowed for Mrs Catalano to be detained and for reasonable force to be used to effect medical treatment. These provisions continued in force until the time of Mrs Catalano’s death on 24 April 2016.

2.4. For this reason Mrs Catalano’s was a death in custody within the meaning of the Coroners Act 2003 and this inquest was held as required by section 21(1)(a) of that Act.

3. Background and medical history 3.1. Mrs Catalano was born in Italy and migrated to Australia in the 1960s. Her husband died in 2003. They had three sons, two of whom have provided a statement3.

3.2. Mrs Catalano’s general practitioner, Dr Bart Mascolo, provided a statement to the Court4. Dr Mascolo conducted duties at the Bene Italian Village Nursing Home where there were approximately 24 patients. Mrs Catalano had resided at the Bene Italian Village Nursing Home since June 2013 following a stroke which resulted in significant decline of her cognitive function.

3.3. Whilst at the home Mrs Catalano experienced behavioural problems relating to dementia and there were regular incidents of emotional and physical outbursts.

Dr Mascolo stated that Mrs Catalano was receiving prescription medication for a 2 Exhibit C8 Statement of the Deputy Registrar of the South Australian Civil and Administration Tribunal and Exhibit C12 3 Exhibits C1b and C4a 4 Exhibit C6

number of health-related issues including ischaemic heart disease, type 2 diabetes, atrial fibrillation and had a history of pancreatitis and hypertension.

4. Mrs Catalano’s unwitnessed fall and decline in health 4.1. One of Mrs Catalano’s carers was registered nurse Vivian Yang. Ms Yang has been employed at the Bene Italian Village since 2014. Ms Yang provided a statement to the Court in which she set out Mrs Catalano's behavioural issues5. Ms Yang stated that despite her behavioural issues, Mrs Catalano was not subject to any physical restraints.

4.2. Ms Yang had been checking Mrs Catalano from 11:30pm on the previous night and saw her both at 2am and 4am. Although she has no specific memory of the 4am check, it was her usual practice to do so.

4.3. Mrs Catalano had a buzzer and a sensor mat placed adjacent to her bed which would activate if stepped on. On that night there was no buzzer or activation of the sensor mat. At 6:45am on 20 April 2016 an enrolled nurse entered Mrs Catalano's room and found her on the floor. The enrolled nurse contacted Ms Yang who attended immediately. Her right leg was bent at the knee, she was on her back and her walking frame was on top of her right leg.

4.4. Dr Mascolo was in attendance and he made arrangements for Mrs Catalano to be conveyed to Modbury Hospital. Mrs Catalano was transferred from the Modbury Hospital to Lyell McEwin Hospital on the same day with a probable fracture which the orthopaedic team had noted on an initial hip X-ray.

4.5. Whilst at the Lyell McEwin Hospital Mrs Catalano had a CT scan of her hip, which did not show a fracture.

4.6. Dr Angeline Khoo6, a resident medical officer at the Lyell McEwin Hospital, saw Mrs Catalano at approximately 9am on 21 April 2016. In her statement Dr Khoo noted that Mrs Catalano had severe end-stage dementia, had been managed by her general practitioner at the Italian Village and provided with quetiapine and antipsychotic medication. Dr Khoo set out Mrs Catalano's medical background of atrial fibrillation and a previous stroke. She noted that Mrs Catalano was taking anticoagulant medication and she had ischaemic heart disease following a heart attack in 2011.

5 Exhibit C7 6 Exhibit C5

Dr Khoo noted she was prescribed medication for her diabetes and had other cardiovascular risk factors including hypertension.

4.7. When Dr Khoo saw Mrs Catalano she was agitated and aggressive. She examined Mrs Catalano and noted she had a urinary catheter with extremely low output. Dr Khoo stated there were a number of health concerns and confirmed that Mrs Catalano was still to receive MET7 calls, but she wanted to speak to the family regarding their mother’s resuscitation status.

4.8. Dr Khoo states that at 11am on 21 April 2016 she spoke to one of Mrs Catalano’s sons, Gabriele, and informed him that his mother was suffering from acute renal failure and reduced urine output. Dr Khoo states she reassured the son the CT of the hip was more accurate than the X-ray and did not show any evidence of a fracture.

4.9. Mr Gabriele Catalano raised concerns with the doctor about marks on his mother’s thigh which he believed were the result of a strap or physical restraint. Dr Khoo advised him to contact Aged Rights Advocacy Services.

4.10. Dr Khoo discussed the issue of resuscitation status with Mr Catalano as during the MET call the previous night ICU had Mrs Catalano noted as 'not for CPR'. Mr Catalano confirmed his mother’s not for resuscitation status.

4.11. Mrs Catalano passed away on 24 April 2016.

5. The death in custody investigation 5.1. Constable Benjamin Jankovic, as part of his investigation8, tested the pressure sensitive mat in Mrs Catalano’s room which did activate an alarm. He also tested the walking frame and applied the handbrakes which both worked correctly. However, he noted: '… when both brakes were applied it was still possible to easily slide the worker across the floor as the floor was covered by lino and did not provide any friction against the surface of the walkers wheels.'

5.2. Constable Jankovic concluded that Mrs Catalano’s death was not suspicious and there was no third party involvement. He stated that the slippery floor may have contributed to Mrs Catalano’s fall.

7 Medical Emergency Treatment 8 Exhibit C9

5.3. Brevet Sergeant Matthew Fullston provided a report to the Court9. His report deals with the marks on Mrs Catalano’s right thigh. Brevet Sergeant Fullston stated that the marks are consistent with the frame of the walker which was found on Mrs Catalano at the time she was discovered beside her bed.

5.4. Brevet Sergeant Fullston concluded that Mrs Catalano had attempted to get out of bed and had fallen due to the slippery surface, with the pressure mat being too small to alert staff. Brevet Sergeant Fullston stated: 'With regard to the treatment that the deceased received within the Bene Italian Aged Care Facility I have not identified any deficiency. Similarly I have not identified any deficiency for the treatment of the deceased while she was within the Lyell McEwin Hospital. '

5.5. Mr Gabriele Catalano attended this inquest and expressed his understandable concern about his mother’s death and particularly the presence of the marks that were present on her right thigh. It was his belief that his mother must have been restrained with a belt and buckle, and he was convinced that there could be no other explanation for those marks. I understand his concerns, but on the material before me I am bound to find that there is no evidence that Mrs Catalano was restrained in the way postulated by her son.

5.6. Brevet Sergeant Fullston, with his investigational expertise, was of the opinion that the marks were consistent with the frame of the walker having pressed against her thigh. I hope that in time, Mr Gabriele Catalano is able to put his mind at rest on this matter. It is my view that Brevet Sergeant Fullston’s explanation is plausible and the most likely explanation for the marks.

5.7. I have no recommendations to make in this matter.

Key Words: Death in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of April, 2019.

State Coroner Inquest Number 06/2019 (0746/2016) 9 Exhibit C12a